title: Stepped care versus standard cognitive-behavioral therapy for obsessive-compulsive disorder: a preliminary study of efficacy and costs.
abstract: BACKGROUND
  Exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) is underutilized, in part because of costs and time requirements. This study extends pilot work investigating the use of a stepped care ERP administration, in which patients are first given a low-intensity, low-cost treatment and the more costly intervention is reserved for those who do not respond to the first intervention.
  
  
  METHODS
  Thirty adults with OCD were randomized to receive stepped care ERP or standard ERP. Those receiving stepped care started with three sessions over 6 weeks of low-intensity counseling with ERP bibliotherapy; patients failing to meet strict responder criteria after 6 weeks were given the more traditional treatment of therapist-administered ERP (17 sessions twice weekly). Those receiving standard ERP received the therapist-administered ERP with no lower-intensity lead-in.
  
  
  RESULTS
  The two treatments were equally efficacious, with 67% of stepped care completers and 50% of standard treatment completers meeting criteria for clinically significant change at posttreatment. Similarly, no differences in client satisfaction ratings were obtained between the two groups. Examination of treatment costs, however, revealed that stepped care resulted in significantly lower costs to patients and third-party payers than did standard ERP, with large effect sizes.
  
  
  CONCLUSIONS
  These results suggest that stepped care ERP can significantly reduce treatment costs, without evidence of diminished treatment efficacy or patient satisfaction. Additional research is needed to determine the long-term efficacy and costs of stepped care for OCD, and to examine the financial and therapeutic impact of implementing stepped care in community settings.
authors.affiliation: Anxiety Disorders Center, The Institute of Living, 200 Retreat Avenue, Hartford, CT 06106, USA. dtolin@harthosp.org
authors.forename: David F
authors.initials: DF
authors.lastname: Tolin
authors.forename: Gretchen J
authors.initials: GJ
authors.lastname: Diefenbach
authors.forename: Christina M
authors.initials: CM
authors.lastname: Gilliam
mesh_terms: D000328:Adult; D001638:Bibliotherapy / Q000191:economics* / Q000379:methods*; D015928:Cognitive Behavioral Therapy / Q000191:economics* / Q000379:methods*; D003131:Combined Modality Therapy / Q000191:economics / Q000379:methods; D003362:Cost-Benefit Analysis; D003376:Counseling / Q000191:economics* / Q000379:methods*; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D007171:Implosive Therapy / Q000191:economics* / Q000379:methods*; D007266:Inhibition, Psychological; D008297:Male; D008875:Middle Aged; D009771:Obsessive-Compulsive Disorder / Q000175:diagnosis / Q000191:economics* / Q000523:psychology / Q000628:therapy*; D010552:Personality Assessment / Q000706:statistics & numerical data; D011594:Psychometrics; D055815:Young Adult